Attachment_5-USAID_Information_Form.docx

J.1 USAID Information Form

Part I: Information About Proposed Activities (all parts mandatory)

1. Name of the proposed awardee of USAID contract or assistance (Firms must include a copy of applicable licenses to do business in Afghanistan)

2. Type of proposed award or other assistance (check one):

|_| Contract or Subcontract |_| Grant or Subgrant |_| Training |_| Equipment |_| Other

3. US$ amount and estimated start/end date of proposed award or assistance:

Dollar amount: $ Start: End:

4. Purpose of proposed award or assistance:

5. Organization proposed to receive award or other assistance:

c. Address:

g. Tribal affiliation or clan

6. Information on Key Individuals associated with the organization named in 5 above, or, if no organization is listed, information on each individual to receive cash or in-kind assistance (including technical assistance). Use continuation sheets as necessary.

** = mandatory information.

Other names used (may include nicknames, pseudonyms not listed under “Name”):**

Gender:**

Current employer and job title:

Occupation:

Address of residence:**

Citizenship(s):** (Afghans: Tribal affiliations and Father’s Name)

Email:

Part II: Contractor/Grantee/Recipient Certification:

Potential Awardee certifies in submitting this form that it has taken reasonable steps (in accordance with sound business practices) to verify the information contained in this form. Contractor/Grantee/Recipient understands that the US Government may rely on the accuracy of such information in processing this vetting request.

Part III: Submission details (to be completed by USG vetting official)

Vetting request number

Staff member who initiated request

Project name

Date submitted for screening

(Use additional continuation sheets as necessary):

Other names used (may include nicknames, pseudonyms not listed under “Name”):**

Gender:**

Current employer and job title:**

Occupation:

Address of residence:**

Citizenship(s):** (Afghans: Tribal affiliations and Father’s Name)

Email:

Other names used (may include nicknames, pseudonyms not listed under “Name”):**

Gender:**

Current employer and job title:**

Occupation:

Address of residence:**

Citizenship(s):** (Afghans: Tribal affiliations and Father’s Name)

Email:

Other names used (may include nicknames, pseudonyms not listed under “Name”):**

Gender:**

Current employer and job title:

Occupation:

Address of residence:**

Citizenship(s):** (Afghans: Tribal affiliations and Father’s Name)

Email:

Other names used (may include nicknames, pseudonyms not listed under “Name”):**

Gender:**

Current employer and job title:

Occupation:

Address of residence:**

Citizenship(s):** (Afghans: Tribal affiliations and Father’s Name)

Email:

INFORMATION FORM INSTRUCTIONS

Please provide information for key individuals of all organizations receiving funds from USAID, including grantees, sub-grantees, Contractors, and vendors, who work in Afghanistan. Please do not provide information for United States citizens or permanent legal residents of the United States.

Part I

Question 1 – Self-explanatory Question 2- Indicate the proposed type of mechanism to be utilized by placing a check mark on the line in front of the appropriate term Question 3 – Enter the amount of award or assistance in US dollars and indicate the start and end date of the program using a mm/dd/yyyy format Question 4 – Indicate the purpose of the award or assistance. Use additional sheets and attach to page one of the vetting form if necessary Question 5 a-g – Self-explanatory.

Attach a copy of the relevant Afghan business license.

Question 6 - “Key Individual” means (i) Any large shareholder: defined as owning 10% or more of an equity stake in the organization, whether publically or privately held; (ii) Principal officers of the organization's governing body (e.g., chairman, vice chairman, treasurer or secretary of the board of directors or board of trustees); (iii) The principal officer and deputy principal officer of the organization (e.g., executive director, deputy director; president, vice president); (iv) The program manager or chief of party for the USAID-financed program; and (v) Any other person with significant responsibilities for administration of USAID financed activities or resources (while a comprehensive list is not possible, this would include any person acting in a role substantially similar to those outlined in (i)-(iv). For Private Security Companies, this would include leadership roles down to the level of field commanders). Complete for each of these four categories or indicate “N/A” if a category does not apply. Use additional pages as needed. Attach copies of photo ID for each “key individual”.

Note: If a “Key Individual” is a US Citizen or Permanent Resident, no information is required.

Part II Individual filling out form must read the Certification and print their name where indicated, sign where indicated, print their title and the name of their organization where indicated, and print the date where indicated.

Part III

This section is not for individual’s information and will be completed by the USG vetting official.

J.2 CONTRACTOR EMPLOYEE BIOGRAPHICAL DATA SHEET

SEE FOLLOWING PAGE

OMB Control No. 0412-0520; Expiration Date: 08/31/2000

CONTRACTOR EMPLOYEE BIOGRAPHICAL DATA SHEET

1. Name (Last, First, Middle)

2. Contractor’s Name

3. Employee’s Address (include ZIP code)

4. Contract Number

5. Position Under Contract

6. Proposed Salary

7. Duration of Assignment

8. Telephone Number (include area code)

9. Place of Birth

10. Citizenship (If non-U.S. citizen, give visa status)

1. Names, Ages, and Relationship of Dependents to Accompany Individual to Country of Assignment

Speaking Proficiency Reading

14. EMPLOYMENT HISTORY

1. Give lasts three (3) years. List salaries separate for each year. Continue on separate sheet of paper if required to list all employment related to duties of proposed assignment.

2. Salary definition – basic periodic payment for services rendered. Exclude bonuses, profit-sharing arrangements, commissions consultant fees, extra or overtime work payments, overseas differential or quarters, cost of living or dependent education allowances.

POSITION TITLE

EMPLOYER’S NAME AND ADDRESS

POINT OF CONTACT &TELEPHONE #

From

To

Dollars

15. SPECIFIC CONSULTANT SERVICES (give last three (3) years)

POINT OF CONTACT &TELEPHONE #

Rate Daily Rate In Dollars

From

To

16. CERTIFICATION: To the best of my knowledge, the above facts as stated are true and correct.

Contractor certifies in submitting this form that it has taken reasonable steps (in accordance with sound business practices) to verify the information contained in this form. Contractor understands that USAID may rely on the accuracy of such information in negotiating and reimbursing personnel under this contract. The making of certifications that are false, fictitious, or fraudulent, or that are based on inadequately verified information, may result in appropriate remedial action by USAID, taking into consideration all of the pertinent facts and circumstances, ranging from refund claims to criminal prosecution.

AID 1420-17 (4/95)

INSTRUCTIONS

Indicate your language proficiency in block 13 using the following numeric interagency Language Roundtable levels (Foreign Service Institute levels). Also, the following provides brief descriptions of proficiency levels 2, 3, 4, and 5. “S” indicates speaking ability and “R” indicates reading ability. For more in-depth description of the levels refer to USAID Handbook 28.

2. Limited working proficiency S Able to satisfy routine social demands and limited work requirements.

R Sufficient comprehension to read simple, authentic written material in a form equivalent to usual printing or typescript on familiar subjects.

3. General professional proficiency

S Able to speak the language with sufficient structural accuracy and vocabulary to participate effectively in most formal and informal conversations.

R Able to read within a normal range of speed and with almost complete comprehension.

4. Advanced professional proficiency

S Able to use the language fluently and accurately on all levels.

R Nearly native ability to read and understand extremely difficult or abstract prose, colloquialisms and slang.

5. Functional native proficiency

S Speaking proficiency is functionally equivalent to that of a highly articulate well-educated native speaker.

R Reading proficiency is functionally equivalent to that of the well-educated native reader.

PAPERWORK REDUCTION ACT INFORMATION

The information requested by this form is necessary for prudent management and administration of public funds under USAID contracts. The information helps USAID estimate overseas logistic support and allowances; the educational information provides an indication of qualifications; the salary information is used as a means of cost monitoring and to help determine reasonableness of proposed salary.

PAPERWORK REDUCTION ACT NOTICE

Public reporting burden for this collection of information is estimated to average thirty minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:

United States Agency for International Development Procurement Policy Division (M/OP/P) Washington, DC 20523-1435;

and Office of Management and Budget Paperwork Reduction Project (0412-0520) Washington, DC 20503

AID 1420-17 (4/95) Back